Improvement Stories

Reinventing Nursing Education

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After 10 years in the marketing department of a small Pittsburgh magazine, Camille Huzzard longed for a new career. “I was a number cruncher. Every day was exactly the same as the day before. I wanted more meaning from my work,” she says. The daughter of a registered nurse, Huzzard at first thought nursing was not for her. “I was a little queasy around blood and gore.” As her job dissatisfaction grew, though, her perspective changed. “I did a lot of soul searching and finally realized that I could really make a difference as a nurse.” Two years ago, at age 37, Huzzard — an Air Force reserve pilot’s wife and mother of a young daughter — enrolled at the University of Pittsburgh Medical Center’s (UPMC) Shadyside School of Nursing.

Her timing was excellent. One of the few remaining hospital-based, two-year diploma programs in the country, the school was about to revamp its curriculum to enhance both the quality of patient care and the job satisfaction of graduates. Embedded in the new program is Transforming Care at the Bedside (TCAB), a national program of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (IHI).

The idea behind TCAB is to improve the quality and safety of patient care on hospital medical and surgical units, improve the effectiveness of the entire care team, engage and improve the patient’s and family members’ experience of care, and increase the vitality and retention of nurses. The TCAB approach includes redesigned processes and workspaces that add value to patient care, and new tools for clear and consistent communication among care team members — and with patients and their families. There are currently 10 hospitals from around the country participating in pilot-testing TCAB techniques and strategies, adopting and spreading the ideas that work best. Another 44 hospitals have been implementing similar innovations as part of the "Transforming Care at the Bedside Collaborative" and 68 hospitals are engaged in the American Organization of Nurse Executives’ (AONE) “Disseminating Transforming Care at the Bedside” project. In every instance, teams begin with small-scale tests of change,” which, once refined and proven successful, are spread to the entire unit, other medical-surgical units, and sometimes other hospitals in a system.

Engaging nurses, the primary bedside caregivers, is a vital element of TCAB, says Pat Rutherford, MS, RN, the IHI vice president who leads the TCAB project. “Unleashing talent at the front lines is critical to the success of TCAB. Nurses and other caregivers on the individual TCAB units lead the innovation efforts to improve patient care. Student nurses participate in the tests of new ideas during their unit rotations and they take those lessons back to the classroom, incorporating these new improvement skills and innovative approaches to care into their curriculum.”

UPMC Shadyside School of Nursing is one of 14 schools that have partnered with TCAB pilot hospitals to redesign nursing education. Its partner is UPMC Shadyside, a 517-bed facility in eastern Pittsburgh, which currently has six TCAB units and expects all its medical-surgical units to be included by the end of 2008, says Susan Christie Martin, MSN, director of UPMC’s Center for Quality Improvement and Innovation. “TCAB has worked out very well for us and we were ready for the next step, bringing TCAB to the classroom,” says Martin. “We encouraged the nursing faculty to look at how work is done and to quickly adopt the thinking that things can be different.”

She acknowledges that it can be unsettling to fit nursing into a new culture. “This is a new frontier we’re working to build. The school invested the time to work with my improvement team to learn the TCAB process and the skills needed.” In 2006, leadership at Shadyside’s nursing school formed a “TCAB-integration” team of faculty members to reshape what was then a more theoretically focused curriculum, says Elaine Patalski, MSN, CRNP, who helped spearhead the redesign. The group examined all four levels of the 22-month program, infusing the TCAB model throughout the existing organizing framework. Students are exposed to TCAB concepts, and real-world adaptations, as they move towards becoming registered nurses.

At level one, students focus on developing nursing assessment skills and learn to prioritize using a “60-Second Priority Assessment” exercise. “Students are learning the concept of safe and reliable patient care and the role of caregiver responsibility at the bedside,” says Patalski. This tool also enables students to develop situational awareness, which involves assessing safety considerations in the patient’s environment.

At level two, students begin to use an essential and well-regarded TCAB tool for professional communication. The tool, SBAR, which stands for Situation-Background-Assessment-Recommendation, provides a clear, consistent format with which to present information and ideas. At this level, students engage with all members of the health care team using SBAR. In addition to using SBAR in the clinical setting, says Patalski, students are encouraged to submit classroom ideas or questions using the SBAR model, making recommendations for problem resolution. Recent graduate Camille Huzzard found the tool extremely useful for patient care. “Being able to contribute and collaborate effectively allowed me to use all my knowledge for the patient’s benefit, and it also made me feel competent and respected.”

Simulations of direct patient care are a major part of level three training. One exercise uses high-fidelity mannequins — equipped with changeable blood pressure, pulse rates, and other vital signs — in crisis situations. After briefly observing the “patient,” students must demonstrate sound critical thinking to decide how to prioritize care. “If the oxygen mask has slipped and the IV drip is too fast, what do you take care of first?” asks Patalski.

Level four is devoted to professional role development — a fundamental underpinning of TCAB’s emphasis on staff satisfaction and retention. For eight to ten weeks at a time, each student follows the schedule of a preceptor — a mentor-nurse on a TCAB unit —and contributes to patient care. This unique service/education partnership, says Patalski, lays the foundation for student-driven tests of change that mark every TCAB unit’s efforts to streamline and improve every aspect of care.

“The mentor nurses model their experience and knowledge for students,” observes Sue Martin. One frequent collaboration involves the tests of change that mark every TCAB unit’s efforts to streamline and improve care. Often led by students, a recent student-suggested innovation is to keep thickened liquids on hand for patients at risk of aspirating thin ones. “Until now, we’ve had to call the dietary department with a special request each time,” says Andrew Thomas, BSN, CMSRN, the director of the medical cardiology unit testing the change. “Keeping a supply on the unit helps us meet patients’ needs more quickly and easily.”

Another innovation tackled the lag time between the arrival of medications from the hospital pharmacy and nurses’ awareness that the medications were in. The solution: a “med arrival alert.” Now the unit clerk wedges a flag-shaped sign in the bedside drawer of each patient awaiting medications to signal a pharmacy delivery.

Though students have been learning on Thomas’s unit — Shadyside’s original TCAB unit — for years, he feels that starting TCAB education in the classroom offers an advantage. “When they get here, they absorb everything right away.”

Though only at the start of her career as an RN, Camille Huzzard is already convinced that TCAB paves the way to career satisfaction and staff retention. Following her student rotation on Thomas’s medical cardiology unit at UPMC Shadyside earlier this year, the hospital offered Huzzard a job on the unit — “which I accepted with pleasure,” she says.

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